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IHS National Pharmacy & Therapeutics Committee National Core Formulary; Last Updated: 09/23/2021 **Note: in GREY indicate removed items.**

Generic Pharmacological Category Formulary Brief (if Notes / Similar NCF Medications Active? Name (up-to-date) available) Miscellaneous Acetaminophen , Miscellaneous Yes Albuterol nebulized Beta2 Yes solution Alendronate Derivative Osteoporosis (2016) Yes Allopurinol Antigout Agent; Xanthine Oxidase Gout (2016) Yes Inhibitor Alogliptin Antidiabetic Agent, Dipeptidyl DPP-IV Inhibitors Yes Peptidase 4 (DPP-4) Inhibitor (2019) , in Yes Pain Mgmt (2014) Antihypertensive; Calcium Channel Yes , Dihydropyridine Blockers (2014) Anastrozole Antineoplastic Agent, Aromatase Yes Inhibitor Apixaban ; Direct Oral Direct Oral Warfarin Yes Anticoagulant (DOAC); Factor Xa (2017) Inhibitor Aspirin Antiplatelet Agent; Nonsteroidal Yes Anti-Inflammatory ; Salicylate Antihypertensive; Beta-Blocker, Beta Blockers (2014) ; Yes Beta1 Selective Atomoxetine , ADHD (2020) / Amphetamine (immediate release); Yes Selective Dextroamphetamine / Amphetamine (long-acting); Methylphenidate (immediate release); Methylphenidate (long-acting) Atorvastatin Antilipemic Agent, HMG-CoA Dyslipidemia Guideline Pravastatin; Rosuvastatin; Yes Reductase Inhibitor Review (2014) Azithromycin , Macrolide STIs - PART 1 (2021) Yes

Printed on 09/26/2021 Page 1 of 16 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category (up-to-date) Formulary Brief Notes / Similar NCF Medications Active? (if available) Miscellaneous Benzoyl Peroxide Topical Skin Product, Acne Acne Treatment Benzoyl Peroxide AND , topical Yes (2020) combination Benzoyl Peroxide AND Clindamycin, Topical Skin Product, Acne; Topical Skin Acne Treatment Benzoyl Peroxide Yes topical combination Product, Acne (Lincosamide Antibiotic) (2020) Bictegravir/emtricitabine/tenofovir Antiretroviral, Integrase Inhibitor (Anti-HIV) HIV Treatment Dolutegravir//; Yes alafenamide (2019) Emtricitabine/tenofovir disoproxil fumarate; Raltegravir Antidepressant, Varenicline; Venlafaxine Yes /Norepinephrine-Reuptake Inhibitor; Dependence Smoking Cessation Aid (2015) , Miscellaneous Antiepileptics Divalproex; ; Levetiracetam; Yes (2014) ; Topiramate Carbidopa-Levodopa (immediate Anti-Parkinson Agent; Decarboxylase Parkinson's Yes release) Inhibitor-Dopamine Precursor Disease (2019) Ceftriaxone Injection Antibiotic, Cephalosporin STIs - PART 1 Cefixime Yes (2021) Chlorthalidone Antihypertensive; Thiazide-Related Diuretic Agents Yes (2014) Citalopram Antidepressant, Selective Serotonin Reuptake SSRIs (2019) ; Fluoxetine; ; Yes Inhibitor Clonazepam Alcohol Lorazepam Yes Withdrawal Syndrome (2015) Clopidogrel Antiplatelet Agent Antiplatelets Aspirin Yes (2015) Corticosteriods (Topical) - High Topical (2018) (Topical) - Intermediate Yes potency (Class I and II) potency; Corticosteroid (Topical) - Low potency Cyanocobalamin ( B12), oral Vitamin, Water Soluble Hematologic Yes Supplements (2016) Dicyclomine Anticholinergic Agent Irritable Bowel Yes Syndrome (2018)

Printed on 09/26/2021 Page 2 of 16 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category (up-to-date) Formulary Brief (if Notes / Similar NCF Medications Active? available) Miscellaneous , Miscellaneous; Digoxin Use (2016) Yes Cardiac Diltiazem Antihypertensive; Calcium Channel Calcium Channel Amlodipine Yes Blocker, Nondihydropyridine Blockers (2014) Divalproex Anticonvulsant, Miscellaneous ER Lithium & Divalproex Carbamazepine; Lamotrigine; Levetiracetam; Yes (2012) Phenytoin; Topiramate Alpha1 Blocker; Antihypertensive Benign Prostatic ; Yes Hypertrophy (2016) Doxycycline Antibiotic, STIs - PART 1 (2021) Yes Duloxetine Antidepressant, Serotonin/Norepinephrine Diabetic Neuropathy Bupropion; Venlafaxine Yes Reuptake Inhibitor/Antagonist (2018) Empagliflozin Antidiabetic Agent, -Glucose SGLT-2 Inhibitors (2019) Yes Cotransporter 2 (SGLT2) Inhibitor Escitalopram Antidepressant, Selective Serotonin SSRIs (2019) Citalopram; Fluoxetine; Paroxetine; Sertraline Yes Reuptake Inhibitor Estradiol tablets Estrogen Derivative Menopausal Hormone Yes Therapy (2016) Ethambutol Antitubercular Agent Isoniazid; Pyrazinamide; Rifampin; Yes Ethinyl estradiol / Contraceptive; Estrogen and Progestin Contraception (2016) Yes Etonogestrel vaginal ring Combination Ethinyl estradiol / Contraceptive; Estrogen and Progestin Contraception (2016) Yes , Combination transdermal Ethosuximide Anticonvulsant, Succinimide Anti-Seizure (2021) Carbamazepine; Clonazepam; Divalproex; Yes Gabapentin; Lamotrigine; Levetiracetam; Phenytoin; Topiramate Ezetimibe Antilipemic Agent, 2-Azetidinone 2018 ACC/AHA Yes Cholesterol Guidelines (2019)

Printed on 09/26/2021 Page 3 of 16 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category Formulary Brief (if Notes / Similar NCF Medications Active? (up-to-date) available) Miscellaneous Finasteride 5 Alpha-Reductase Inhibitor Benign Prostatic Yes Hypertrophy (2016) Fluoxetine Antidepressant, Selective Serotonin Sertraline Yes Reuptake Inhibitor / Beta2 Agonist, Long-Acting; LABAs (2019) Mometasone (Asmanex®) Yes Corticosteroid, Inhalant Antihypertensive; Loop Diuretic Failure Overview Yes (2017) Gabapentin Anticonvulsant, Miscellaneous; GABA Gabapentin & Pregabalin in Yes Analog Pain (2014) Glecaprevir/pibrentasvir Antihepaciviral HCV Treatment (2018) Ledipasvir/sofosbuvir (Harvoni®); Yes (Mavyret®) Sofosbuvir/velpatasvir (Epclusa®) Glipizide Antidiabetic Agent; Sulfonylurea Sulfonylureas (2015) Yes Hydrochlorothiazide Antihypertensive; Thiazide Diuretic (2014) Chlorthalidone Yes Hydroxychloroquine Antimalarial Non-biologic DMARDs Leflunomide; Methotrexate; Sulfasalazine Yes (2016) , First Anxiety Disorders (2021) Yes Generation Ibuprofen Nonsteroidal Anti-Inflammatory Drug NSAIDs (2014) ; Indomethacin; Meloxicam; Naproxen Yes Indomethacin Nonsteroidal Anti-Inflammatory Drug NSAIDs (2014) Diclofenac; Ibuprofen; Meloxicam; Naproxen Yes Isoniazid Antitubercular Agent Ethambutol; Pyrazinamide; Rifampin; Rifapentine Yes Isosorbide mononitrate Agent; Vasodilator Nitroglycerin 0.4 Milligrams; Sublingual; Yes Nitroglycerin patch

Printed on 09/26/2021 Page 4 of 16 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category Formulary Brief (if Notes / Similar NCF Medications Active? (up-to-date) available) Miscellaneous Lactulose Ammonium Detoxicant; , Cirrhosis & Polyethylene glycol Yes Osmotic Complications (2015) Lamotrigine Anticonvulsant, Miscellaneous Antiepileptics (2014) Carbamazepine; Divalproex; Levetiracetam; Yes Phenytoin; Topiramate Ledipasvir/sofosbuvir Antihepaciviral HCV Treatment (2018) Glecaprevir/pibrentasvir (Mavyret®); Yes (Harvoni®) Sofosbuvir/velpatasvir (Epclusa®) Leflunomide Antirheumatic, Disease Modifying Non-biologic DMARDs Hydroxychloroquine; Methotrexate; Sulfasalazine Yes (2016) Letrozole Antineoplastic Agent, Aromatase Yes Inhibitor Levetiracetam Anticonvulsant, Miscellaneous Antiepileptics (2014) Carbamazepine; Divalproex; Lamotrigine; Yes Phenytoin; Topiramate Agent Yes Lisinopril Antihypertensive, ACEIs & ARBs in Heart Yes Angiotensin-Converting Inhibitor Failure (2017) Lithium Antimanic Agent ER Lithium & Divalproex Yes (2012) Loperamide Antidiarrheal Irritable Bowel Syndrome Yes (2018) Lorazepam Benzodiazepine Alcohol Withdrawal Clonazepam Yes Syndrome (2015) Losartan Antihypertensive, Angiotensin II ACEIs & ARBs in Heart Yes Blocker Failure (2017) Medroxyprogesterone Contraceptive, Progestin Contraception (2016) Medroxyprogesterone, oral; Oral contraceptive pill, Yes acetate, injection (Injection/Depot) progestin only Medroxyprogesterone, oral Contraceptive; Progestin Polycystic Ovarian Medroxyprogesterone acetate, injection; Oral Yes Syndrome (2017) contraceptive pill, progestin only

Printed on 09/26/2021 Page 5 of 16 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Pharmacological Category Formulary Brief (if Notes / Similar NCF Medications Active? Name (up-to-date) available) Miscellaneous Meloxicam Nonsteroidal Anti-Inflammatory Drug NSAIDs (2014) Diclofenac; Ibuprofen; Indomethacin; Naproxen Yes Memantine N-Methyl-D-Aspartate (NMDA) Yes Antidiabetic Agent; Biguanide Yes Methimazole ; Yes (2021) Methotrexate Antineoplastic Agent; Antirheumatic; Non-biologic Hydroxychloroquine; Leflunomide; Sulfasalazine Yes Disease Modifying; Immunosuppresant DMARDs (2016) Agent Metoprolol Antihypertensive; Beta-Blocker, Beta1 Beta-blockers in Heart Atenolol; Propranolol Yes Selective Failure (2017) Moisturizers (both cream- Skin and Mucous Membrane Agent, Atopic Dermatitis Corticosteriods (Topical) - High potency (Class I and II); Yes AND petroleum-based) Miscellaneous; Topical Skin Product (2020) Corticosteroid (Topical) - Intermediate potency; Corticosteroid (Topical) - Low potency; Montelukast Leukotriene Receptor Antagonist Yes Naloxone ; Opioid Antagonist Treatment of Opioid Yes Overdose (2014) Naltrexone, oral Antidote; Opioid Antagonist Alcohol Use Disorders Naloxone Yes (2015) Naproxen Nonsteroidal Anti-Inflammatory Drug NSAIDs (2014) Diclofenac; Ibuprofen; Indomethacin Yes Nitroglycerin 0.4 Antianginal Agent; Antidote, Isosorbide mononitrate; Nitroglycerin patch Yes milligrams, sublingual Extravasation; Vasodilator Nitroglycerin patch Antianginal Agent; Antidote, Isosorbide mononitrate; Nitroglycerin 0.4 milligrams; Yes Extravasation; Vasodilator Sublingual Nortriptyline Antidepressant, Tricyclic Antidepressants in Amitriptyline Yes Pain Mgmt (2014)

Printed on 09/26/2021 Page 6 of 16 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Pharmacological Category Formulary Brief (if Notes / Similar NCF Medications Active? Name (up-to-date) available) Miscellaneous ; Selective 5-HT3 Antiemetic Agents (2021) Yes Receptor Antagonist Oseltamivir Antiviral Agent; Neuraminidase Treatment of Influenza Yes Inhibitor (2019) Anticonvulsant, Miscellaneous Anti-Seizure Drugs (2021) Carbamazepine; Clonazepam; Divalproex; Gabapentin; Yes Lamotrigine; Levetiracetam; Phenytoin; Topiramate Oxybutynin, Antispasmodic Agent, Urinary Antimuscarinics (2019) Oxybutynin, Immediate-release Yes Extended-release Oxybutynin, Antispasmodic Agent, Urinary Antimuscarinics (2019) Oxybutynin, Extended-release Yes Immediate-release Paroxetine Antidepressant, Selective SSRIs (2019) Citalopram; Escitalopram; Fluoxetine; Sertraline Yes Serotonin Reuptake Inhibitor Penicillin G benzathine Antibiotic, Penicillin STIs - PART 1 (2021) Yes Phentermine Central Obesity Treatment (2018) Yes Phenytoin Anticonvulsant, Antiepileptics (2014) Carbamazepine; Divalproex; Lamotrigine; Levetiracetam; Yes Topiramate Pioglitazone Antidiabetic Agent, Thiazolidinediones (2017) Yes Thiazolidinedione Pramipexole Anti-Parkinson Agent, Dopamine /Sleep Yes Agonist Medications (2021) Pravastatin Antilipemic Agent, HMG-CoA Hyperlipidemia (2017) Atorvastatin; Rosuvastatin; Simvastatin Yes Reductase Inhibitor Prazosin Alpha1 Blocker; Antihypertensive PTSD Indication (2012) Doxazosin; Tamsulosin Yes Prednisone Corticosteroid, Systemic Yes

Printed on 09/26/2021 Page 7 of 16 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Pharmacological Category Formulary Brief (if Notes / Similar NCF Medications Active? Name (up-to-date) available) Miscellaneous Propranolol Antihypertensive; Beta-Blocker, Beta Blockers (2014) Atenolol; Metoprolol Yes Non-Selective Propylthiouracil Antithyroid Agent; Thioamide Hyperthyroidism (2021) Methimazole Yes Pyrazinamide Antitubercular Agent Ethambutol; Isoniazid; Rfapentine ; Rifampin Yes Pyridoxine (Vitamin B6) Vitamin, Water Soluble Supplements in Yes Obstetrics (2016) Rifampin Antitubercular Agent Ethambutol; Isoniazid; Pyrazinamide; Rifapentine Yes Rifapentine Antitubercular Agent Rifapentine (2013) Ethambutol; Isoniazid; Pyrazinamide; Rifampin Yes Rosuvastatin Antilipemic Agent, HMG-CoA Hyperlipidemia (2017) Atorvastatin; Pravastatin; Simvastatin Yes Reductase Inhibitor Salsalate Salicylate Yes Sertraline Antidepressant, Selective Serotonin Citalopram; Escitalopram; Fluoxetine; Paroxetine Yes Reuptake Inhibitor Simvastatin Antilipemic Agent, HMG-CoA Dyslipidemia Guideline Atorvastatin; Pravastatin; Rosuvastatin Yes Reductase Inhibitor Review (2014) Sofosbuvir/velpatasvir Antihepaciviral HCV Treatment (2018) Glecaprevir/pibrentasvir (Mavyret®); Ledipasvir/sofosbuvir Yes (Epclusa®) (Harvoni®) Antihypertensive; Mineralocorticoid Yes Receptor Antagonists; Receptor Antagonist in Sparing Diuretic HF (2017) Sulfasalazine 5-Aminosalicylic Acid Derivative Hydroxychloroquine; Leflunomide; Methotrexate Yes Tacrolimus Calcineurin Inhibitor; Atopic Dermatitis (2020) Corticosteriods (Topical) - High potency (Class I and II); Yes Immunosuppressant Agent; Topical Corticosteroid (Topical) - Intermediate potency; Corticosteroid Skin Product (Topical) - Low potency; Moisturizers (both cream- AND petroleum-based)

Printed on 09/26/2021 Page 8 of 16 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category (up-to-date) Formulary Brief (if Notes / Similar NCF Medications Active? available) Miscellaneous Tamoxifen Antineoplastic Agent, Estrogen Receptor Antagonist; Yes Selective Estrogen Tamsulosin Alpha1 Blocker Benign Prostatic Doxazosin; Prazosin Yes Hypertrophy (2016) Topiramate Anticonvulsant, Miscellaneous Antiepileptic Carbamazepine; Divalproex; Yes Medications (2014) Lamotrigine; Levetiracetam; Phenytoin Ulipristal Contraceptive; Progestin Receptor Modulator Contraception (2016) Levonorgestrel (Plan B One-Step®) Yes Umeclidinium/ Long-Acting (LAMA) / LAMAs (2019) Tiotropium (Spiriva®) Yes Long-Acting Beta2 Agonist (LABA) Varenicline Partial Nicotine Agonist, Smoking Cessation Aid Nicotine Dependence Bupropion Yes (2015) Venlafaxine Antidepressant, Serotonin/Norepinephrine Reuptake SNRIs (2012) Bupropion; Duloxetine Yes Inhibitor/Antagonist Warfarin Anticoagulant; Vitamin K Antagonist Direct Oral Apixaban; Low-molecular weight Yes Anticoagulants (2017) heparin Calcium Electrolyte supplement *Any formulation* Yes Diclofenac Nonsteroidal Anti-Inflammatory Drug NSAIDs (2014) *Any formulation* Ibuprofen; Indomethacin; Meloxicam; Yes Naproxen Fluoride, oral Nutritional Supplement Supplements in Oral *Any oral Yes Health (2016) formulation* Iron, oral Iron Salt Hematologic *Any oral Yes Supplements (2016) formulation* Albuterol, metered dose Beta2 Agonist NPTC Meeting Update *Any product* Yes inhaler (MDI) (Nov 2017) Atypical Antipsychotic, Atypical *Any product* lauroxil; Yes Agents (2015) decanoate

Printed on 09/26/2021 Page 9 of 16 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category Formulary Brief (if Notes / Similar NCF Medications Active? (up-to-date) available) Miscellaneous Corticosteroid (Topical) - Topical Corticosteroids *Any product* Corticosteriods (Topical) - High potency (Class I and II); Yes Intermediate potency Corticosteroid (Topical) - Low potency Corticosteroid (Topical) - Low Topical Corticosteroids *Any product* Corticosteriods (Topical) - High potency (Class I and II); Yes potency Corticosteroid (Topical) - Intermediate potency Corticosteroid, intranasal Intranasal Corticosteroid *Any product* Yes Estrogen vaginal cream Estrogen Derivative NPTC Meeting Update *Any product* Estradiol tablets Yes (May 2018) H1 Antagonist (2nd generation), Histamine H1 Antagonist, *Any product* Yes long-acting Second Generation Laxative, bulk-forming Bulk-forming Laxative *Any product* Yes Laxative, stimulant Stimulant Laxative *Any product* Yes Low-molecular weight heparin Low-molecular Weight Heparin VTE Prophylaxis (2011) *Any product* Yes Ophthalmic Analog Ophthalmic Prostaglandin Ophth Prostaglandin *Any product* Yes Analog Analogs (2018) Oral contraceptive pill, extended Contraceptive Contraception (2016) *Any product* Yes cycle Oral contraceptive pill, monophasic: Contraceptive *Any product* Monophasic: 30-35mcg EE (medium); Oral contraceptive Yes 20mcg EE (low) pill Oral contraceptive pill, monophasic: Contraceptive *Any product* Monophasic: 20mcg EE (low) ; Oral contraceptive pill Yes 30-35mcg EE (medium) Oral contraceptive pill, progestin Contraceptive *Any product* Etonogestrel; Implant; Intrauterine Device; Yes only Levonorgestrel Oral contraceptive pill, triphasic Contraceptive *Any product* Monophasics ; Oral Contraceptive Pill Yes

Printed on 09/26/2021 Page 10 of 16 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category Formulary Brief (if Notes / Miscellaneous Similar NCF Active? (up-to-date) available) Medications Phosphodiesterase 5 (PDE5) Inhibitor Phosphodiesterase-5 Enzyme Phosphodiesterase 5 *Any product* Yes Inhibitor Inhibitors (2018) Polyethylene glycol Laxative, Osmotic Irritable Bowel Syndrome *Any product* Lactulose Yes (2018) Proton Pump Inhibitor Proton Pump Inhibitor GERD & PUD (2018) *Any product* Yes Tretinoin, topical Topical Skin Product, Acne Acne (2013) *Any product* Yes Vitamin D Vitamin D Analog Vitamin D (2010) *Any product* Yes Vitamin D Analog (Topical) Vitamin D Analog Psoriasis (2018) *Any product* Yes Intrauterine device, copper Contraceptive Contraception (2016) *Any product*; For use by a skilled and Intrauterine device, Yes privileged provider levonorgestrel Intrauterine device, levonorgestrel Contraceptive, Progestin Contraception (2016) *Any product*; For use by a skilled and Intrauterine device, Yes privileged provider copper Insulin / Regular human (NovoLIN® R) Insulin, Short-Acting Insulins (2015) *Branded product* Yes Insulin NPH (NovoLIN® N) Insulin, Intermediate-Acting Insulins (2015) *Branded product* Yes Insulin NPH / Regular human insulin Insulin, Combination (70/30 Mix) Insulins (2015) *Branded product* Yes (NovoLIN® 70/30) Levonorgestrel (Plan B One-Step®) Contraceptive, Progestin Contraception (2016) *Branded product* Ulipristal Yes Mometasone (Asmanex®) Corticosteroid, Inhalant *Branded product* Yes Tiotropium (Spiriva®) Long-Acting Anticholinergic Inhaled Anticholinergics *Branded product* Yes Agent (2011)

Printed on 09/26/2021 Page 11 of 16 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Formulary Brief Notes / Miscellaneous Similar NCF Medications Active? Category (up-to-date) (if available) Insulin aspart (NovoLog®) Insulin, Rapid-Acting Insulins (2015) *Branded product*; Pen Device Yes Insulin aspart / Insulin aspart Insulin, Combination Insulins (2015) *Branded product*; Pen Device Yes protamine (NovoLog® Mix 70/30) (70/30 Mix) Insulin detemir (Levemir®) Insulin, Long-Acting Insulins (2015) *Branded product*; Pen Device Insulin glargine (Lantus®) Yes Antihypertensive; Beta-blockers in *Immediate-release only Atenolol; Metoprolol; Propranolol Yes Beta-Blocker with Alpha-Blocking Activity (2017) Dolutegravir/abacavir/lamivudine Antiretroviral, Integrase HIV Treatment *Note: HLA B5701 testing required prior to Bictegravir/emtricitabine/tenofovir Yes Inhibitor (Anti-HIV) (2019) initiation alafenamide; Dolutegravir; Emtricitabine/tenofovir disoproxil fumarate; Raltegravir Buprenorphine-naloxone (**REMS Analgesic, Opioid; Opioid Use **See REMS here** Naloxone Yes drug**) Analgesic, Opioid Partial Disorder (2018) Agonist Buprenorphine, long-acting Analgesic, Opioid; MAT for OUD Any formulation; Restricted to treatment of Buprenorphine, short-acting (**REMS Yes (**REMS drug**) Analgesic, Opioid Partial (2021) Opioid Use Disorder; **See REMS here** drug**); Buprenorphine-naloxone (**REMS Agonist drug**) Buprenorphine, short-acting Analgesic, Opioid; MAT for OUD Any formulation; Restricted to treatment of Buprenorphine, long-acting (**REMS Yes (**REMS drug**) Analgesic, Opioid Partial (2021) Opioid Use Disorder; **See REMS here** drug**); Buprenorphine-naloxone (**REMS Agonist drug**) Naltrexone, extended-release for Antidote; Opioid Opioid Use **See REMS here** Yes injection (**REMS drug**) Antagonist Disorder (2018) * Histamine GERD & PUD *(April 1, 2020) The Food and Drug Proton Pump Inhibitor Yes (2018) Administration has recommended that all formulations of ranitidine be taken off the market due to contaminates of N-Nitrosodimethylamine (NDMA), a , in ranitidine products. Donepezil Acetylcholinesterase 5mg and 10mg strengths Yes Inhibitor (Central) Antibiotic, Rifamycin Hepatic After failure of, or intolerance to, lactulose Lactulose Yes Encephalopathy monotherapy as indicated for hepatic (2020) encephalopathy , All ACIP-recommended Vaccines (2011) All ACIP recommended vaccines for routine Yes use in accordance with ACIP guidelines Epinephrine Injection Devices Alpha-/Beta- Agonist Epinephrine Any device, auto-injector or pre-filled syringe Yes (both 0.15mg and 0.3mg) Injection Devices (2020

Printed on 09/26/2021 Page 12 of 16 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category Formulary Brief (if Notes / Miscellaneous Similar NCF Medications Active? (up-to-date) available) Glucose, Oral Antidote Glucagon Delivery Any formulation Glucagon Yes Devices (2021) Folic Acid Vitamin, Water Soluble Supplements in Any product containing >400 mcg / daily dose Yes Womens Health (2016) Serotonin 5-HT1 agonist Antimigraine Agent; Serotonin 5-HT Triptans (2016) Any two (2) triptan medications are required, one Yes (Triptan) 1B/1D Receptor Agonist must be sumatriptan Sumatriptan Antimigraine Agent; Serotonin 5-HT Triptans (2016) Any two (2) triptan medications are required, one Yes 1B/1D Receptor Agonist must be sumatriptan Nicotine replacement Smoking Cessation Aid Nicotine Combination NRT (nicotine patches + any Bupropion; Varenicline Yes therapy (NRT), Dependence (2015) short-acting NRT product) combination Semaglutide, dulaglutide ===REMOVED from NCF=== Dulaglutide removed from NCF; liraglutide and No or liraglutide semaglutide remain on NCF Raltegravir Antiretroviral, Integrase Inhibitor HIV Treatment For (1) HIV Post-Exposure Prophylaxis (with Emtricitabine/tenofovir Yes (Anti-HIV) (2019) emtricitabine/ tenofovir DF) or (2) HIV Treatment disoproxil fumarate (with emtricitabine/tenofovir DF) in patients with contraindications for 1st line anti-HIV agents Emtricitabine/tenofovir Antiretroviral, Reverse Transcriptase HIV Pre-Exposure For (1) Pre-Exposure HIV Prophylaxis, (2) Raltegravir Yes disoproxil fumarate Inhibitor, Nucleoside (Anti-HIV); Prophylaxis (PrEP) Post-Exposure HIV Prophylaxis (with raltegravir) or Antiretroviral, Reverse Transcriptase (2018) (3) HIV Treatment (with raltegravir) in patients with Inhibitor, Nucleotide (Anti-HIV) contraindications for 1st line anti-HIV agents Dolutegravir Antiretroviral, Integrase Inhibitor HIV Updates (2020) For HIV treatment in pregnant patients Emtricitabine/tenofovir Yes (Anti-HIV) disoproxil fumarate; Raltegravir Cefixime Antibiotic, Cephalosporin STIs - PART 1 For outpatient treatment of gonorrhea for Expedited Ceftriaxone Injection Yes (2021) Partner Therapy or when injection therapy is not possible Glucagon Antidote; For outpatient use Yes Sevelamer carbonate Phosphate Binder Phosphate Binders For patients on dialysis who cannot use Calcium Yes (2018) calcium-based phosphate binders due to hypercalcemia Etonogestrel, implant Contraceptive; Progestin Contraception For use by a skilled and privileged provider Oral contraceptive pill, Yes (2016) progestin only Antipsychotic, Atypical (Second Long-Acting Injectable Yes Generation) - Injectable Injectable (2020)

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Generic Medication Name Pharmacological Category (up-to-date) Formulary Brief (if Notes / Miscellaneous Similar NCF Medications Active? available) Haloperidol decanoate Antipsychotic, Typical (First Generation) - Long-Acting Injectable Injectable Aripiprazole lauroxil Yes Injectable Antipsychotics (2020) Prenatal Multivitamin Vitamin & Prenatal Must contain >400 mcg of Yes Care (2021) folic acid/dose Adalimumab -OR- Etanercept Antirheumatic, Disease Modifying; Tumor TNF Inhibitors (2016) ONLY In consultation with Etanercept -OR- Adalimumab (can Yes (can choose either product) Necrosis Factor (TNF) Blocking Agent a rheumatologist choose either product) Etanercept -OR- Adalimumab Antirheumatic, Disease Modifying; Tumor TNF Inhibitors (2016) ONLY In consultation with Adalimumab -OR- Etanercept (can Yes (can choose either product) Necrosis Factor (TNF) Blocking Agent a rheumatologist choose either product) Dextroamphetamine / Central Nervous System Stimulant Pediatric use only Dextroamphetamine and Yes Amphetamine (immediate release) amphetamine (long-acting) Dextroamphetamine / Central Nervous System Stimulant Pediatric use only Dextroamphetamine and Yes Amphetamine (long-acting) amphetamine (immediate release) Methylphenidate (immediate Central Nervous System Stimulant Pediatric use only Methylphenidate (long-acting) Yes release) Methylphenidate (long-acting) Central Nervous System Stimulant Pediatric use only Methylphenidate (immediate Yes release) Angiotensin receptor blocker ===REMOVED from NCF=== (see Losartan) Angiotensin II Receptor Removed April 2012 Losartan No Antagonists (2014) Dyslipidemia Guidelines Removed April 2012 Atorvastatin; Pravastatin; No Review (2014) Rosuvastatin; Simvastatin Isosorbide dinitrate ===REMOVED from NCF=== (see Removed Aug 2013 Isosorbide mononitrate No Isosorbide mononitrate) Ipratropium, MDI ===REMOVED from NCF=== COPD Inhalers (2015) Removed Aug 2015 Albuterol, metered dose inhaler No (MDI); Tiotropium (Spiriva®) Lopinavir / (Kaletra®) ===REMOVED from NCF=== (see HIV PrEP (2018) Removed August 2013 No Emtricitabine/tenofovir) (controlled or extended Calcium Channel Removed August 2014 Amlodipine No release) Blockers (2014)

Printed on 09/26/2021 Page 14 of 16 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category (up-to-date) Formulary Brief (if Notes / Similar NCF Medications Active? available) Miscellaneous ===REMOVED from NCF=== (see Diltiazem) Calcium Channel Blockers Removed August Diltiazem No (2014) 2014 Gemfibrozil ===REMOVED from NCF=== Dyslipidemia Guidelines Removed Feb No Review (2014) 2014 (enteric ===REMOVED from NCF=== (see Proton Pump Long-Term Use of PPIs Removed Feb Proton Pump Inhibitor No coated) Inhibitor) (2014) 2014 Fibric Acid Derivative ===REMOVED from NCF=== Hyperlipidemia (2017) Removed Feb No 2017 Niacin extended release ===REMOVED from NCF=== Hyperlipidemia (2017) Removed Feb No (Niaspan®) 2017 Saxagliptin ===REMOVED from NCF=== (see Alogliptin) DPP-IV Inhibitors (2019) Removed Feb Alogliptin No 2019 Trospium ===REMOVED from NCF=== (see Oxybutynin ER, Antimuscarinics (2019) Removed Feb Oxybutynin, Extended-release; No IR) 2019 Oxybutynin, Immediate-release Prazosin in PTSD (2012) Removed Jan Doxazosin; Prazosin; Tamsulosin No 2012 Clindamycin, topical ===REMOVED from NCF=== (See Benzoyl Removed January No Peroxide AND Clindamycin, topical combination) 2020 Mometasone / ===REMOVED from NCF=== (see LABAs (2019) Removed June Fluticasone/salmeterol No (Dulera®) Fluticasone/salmeterol) 2019 ===REMOVED from NCF=== (see Nortriptyline) Antidepressant Use in Removed May Nortriptyline No Chronic Pain (2014) 2014 Sulindac NSAIDs in Chronic Pain Removed May Diclofenac; Ibuprofen; Indomethacin; No (2014) 2014 Meloxicam; Naproxen Glyburide ===REMOVED from NCF=== (see Glipizide) Sulfonylureas (2015) Removed May Glipizide No 2015 Conjugated estrogen ===REMOVED from NCF=== (see Estrogen vaginal NPTC Meeting Update Removed May Estrogen vaginal cream No vaginal cream, (Premarin) cream) (May 2018) 2018

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Generic Medication Pharmacological Category (up-to-date) Formulary Brief (if Notes / Miscellaneous Similar NCF Medications Active? Name available) Insulin glargine ===REMOVED from NCF=== (see Insulin NPTC Meeting Update Removed May 2019 Insulin detemir (Levemir®) No (Lantus®) detemir) (May 2019) Dulaglutide ===REMOVED from NCF=== NPTC Meeting Update Removed Nov 2020 No (2020) Fluticasone / Salmeterol Removed Oct 2012 Fluticasone/salmeterol No (Advair®) ===REMOVED from NCF=== Insomnia (2015) Removed Oct 2015 No Salmeterol (Serevent®) ===REMOVED from NCF=== Inhaled Anticholinergics Removed Sept 2011 No (2011) Dedicated emergency Contraception (2016) Removed Sept 2013 Levonorgestrel (Plan B No contraceptive One-Step®); Ulipristal Liraglutide or Antidiabetic Agent, Glucagon-Like GLP-1 Receptor Select either of these subcutaneous Yes semaglutide Peptide-1 (GLP-1) Receptor Agonist (2019) agents, no preference given Semaglutide or Antidiabetic Agent, Glucagon-Like GLP-1 Receptor Select either of these subcutaneous Yes liraglutide Peptide-1 (GLP-1) Receptor Agonist Agonists (2019) agents, no preference given

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